Rhode Island Pediatric Patient Centered Medical Home Initiative February 7, 2013 4:30-6:00 PM Introductions • Patricia Flanagan, MD, Co-Chair, Hasbro Children’s Hospital • Elizabeth Lange, MD, Co-Chair, Waterman Pediatrics Opening Remarks • Steven Costantino, Secretary, Executive Office of Health and Human Services • Christopher Koller, Commissioner, Office of the Health Insurance Commissioner • Michael Fine, MD, Director, Rhode Island Department of Health • William Hollinshead, MD, MPH, President, Rhode Island American Academy of Pediarics Children, Families and the Medical Home: Why do we need “CSI-Kids”? David Keller MD Project co-Director, CSI-RI Objectives After my talk, you should be able to: • Describe the current health status of Rhode Island’s children and youth • Explain the healthcare needs of children that must be met in rapidly changing healthcare environment – Healthy children – Children with special health care needs • Name an example showing how RI’s children fit into models proposed by the Affordable Care Act How are the children? #25 of 50 How’s their health? #19 of 50 Why? Look at the details: Indicator Rate Rank MORTALITY Infant 6.2 per 1000 births 23rd Child 16 per 100,000 children 16th Teen 40 per 100,00 teens 6th NEWBORNS Low birth weight 7.7 % 18th CHILDREN Lead level > 10 mg/dl 3% Child maltreatment 15 per 1000 children 42nd TEENS Teen births 22 per 1000 teens 7th Substance abuse 8% 30th Furthermore Indicator Rate EARLY CHILDHOOD Enrolled in EI 11% Eligible in HeadStart 40% Overweight 25% SCHOOL AGE Chronic Early Absences 12% 4th Grade Reading 71% 4th Grade Math 65% HIGH SCHOOL Graduation 77% Teens not in school/ not working 8% Children with Special Health Care Needs • 17.3% of RI children have a special health care need (per CSHCN screener) – Allergies, developmental delay, ADHD, asthma • More than 25% of CSHCN – Behavioral problems, anxiety, depression, migraines, ASD • More than 15% of CSHCN • 97% have a “source of regular care” • 30% got help with care coordination From J Griffin, Analysis of National Survey of Children with Special Health Care Needs Rhode Island Sample - 2009/10 DHHS CHCSN are high risk Medicaid Enrollees and Expenditures, FY 2009 Disabled 15% Elderly 10% Disabled 43% Adults 26% Elderly 23% Children 49% Adults 14% Children 21% Enrollees Total = 62.6 million Expenditures Total = $346.5 billion NOTE: Percentages may not add up to 100 due to rounding. SOURCE: KCMU/Urban Institute estimates based on data from FY 2009 MSIS and CMS-64, 2012.MSIS FY 2008 data were used for MA, PA, UT, and WI, but adjusted to 2009 CMS-64. But still, common things cost the most Why a Pediatric Medical Home? • Pediatricians (and FP, NP, PA) see children before they start school – Able to screen – Able to refer – Able to follow up • Children and families with SHCN need help in accessing medical and other services • Coordinated care will assure that services are used early and effectively, saving some cost now and a whole lot later The ACA is a scaffold to build on In the ACA: • Increase access: – Covered lives – Medicaid/ Exchanges In Rhode Island: • Medicaid expansion • Exchange • Transform care system: – Focus on quality – Teams/ Reporting/ Payment • Beacon Initiative • CEDARR (Health Homes) • Innovation grants (asthma, smoking) • Payment Reform: – Try new ways – Take them to scale • CSI-RI (MAPCP) • ACO (Coastal) 1 5 The Medical Home: A Practice with benefits Used with permission of Ed Paul MD, Yuma Regional Medical Center American Academy of Pediatrics and Medical Homes Elizabeth B. Lange, MD FAAP Past- President, RIAAP Pediatrician, Waterman Pediatrics/Coastal Medical History • 1967 – AAP first uses the term “medical home” – Definition : One central source for a child’s pediatric records , especially children with special health care needs • 1980s – AAP broadens the medical home concept – The provision of primary care that emphasizes the total health, education, family support and social environment needs of the child • 1990s – AAP publishes policy statement and partners with Family Voices, focuses medical home on children with special health care needs • 2000s – AAP defines care coordination, includes parent partners • 2007 – AAP collaborates with AAFP, ACP, AOA to write the Joint Principles of the Patience Centered Medical Home Joint Principles of the Patient Centered Medical Home (PCMH) • Developed in February 2007 • American Academy of Pediatrics (AAP) , American Academy of Family Practice (AAFP), American College of Physicians (ACP), American Osteopathic Society (AOA) • Outlined characteristics of the PCMH – – – – – – – Personal physician Physician-directed medical practice Whole person orientation Coordinated, integrated care Quality and safety Enhanced access Appropriate payment Source: http://www.medicalhomeinfo.org/downloads/pdfs/JointStatement.pdf AAP Preamble to the Joint Principles of the PCMH • The AAP elaborated on the joint principles by creating a preamble that advocates for the following dimensions of the pediatric medical home – – – – Family-centered partnership Community-based system Transitions Value Pediatric Medical Homes Is it Patient Centered or Family- Centered? IT’S BOTH! Pediatric Medical Homes are a patient- and family-centered partnership that is built on a trusting, collaborative and working relationship with families, respecting their diversity and recognizing that the family is the constant in a child’s life. FCMH: Focused on Prevention Childhood is the time to build health Pediatric Visits: 2002-8 Healthy childhood lifestyles => prevented adult chronic illness Preventive care Acute care Chronic care FCMH is when you can improve population health (the Triple Aim) Pre/post surgical care From 2003-2008 National Ambulatory Medical Care Survey (MD office visits for children 0-21 yrs) The Medical Home: Health Care Access and Impact for Children and Youth • Results of 2007 National Survey of Children’s Health • 56.9% of US children ages 1-17 years had a medical home • These children are more likely to have preventive health visits and their medical and dental needs met Strickland, et al. 2011. Pediatrics 127(4); 604-611. Medical Home Cost Savings Families with children with special health care needs (CSHCN) incur lower out-of-pocket medical costs when their children receive health care in a setting in which the carecoordination component of the medical home is in place. In turn, these families are less likely to report financial stress attributable to medical expenses incurred by those children. Pediatrics 2011:128:892-900 Improved Outcomes Associated with Medical Home in Pediatric Primary Care • 6 conditions studied (asthma, diabetes, cerebral palsy, epilepsy, ADHD, and autism). • Results: some medical home measures correlated with lower hospitalization rates. • Higher chronic-condition management scores were associated with lower ER usage. Cooley, et al. Pediatrics. 2009;124(1);358-364 Colorado Medicaid and SCHIP PCMH for low-income children • Median annual costs $785 for PCMH children compared to $1000 for control • PCMH children in Denver with chronic conditions had lower median annual costs ($2,275) than those not enrolled in a PCHM practice ($3,404) • 72% of children in PCMH practices had well child visits, compared to 27% of controls Kevin Grumbach, MD and Paul Grundy, MD, MPH Outcomes of Implement Patient Centered Medical Home Interventions, November 16, 2011 Patient-Centered Primary Care Collaborative at http://www.pcpcc.net/files/evidence_outcomes_in_pcmh.pdf accessed 3/22/11 Case Management Cost Savings In the fiscal years of 2007 – 2010, children age 20 and younger enrolled in the Community Care of North Carolina networks for the Division of Medical Assistance, cost the state healthcare budget, on a per-member-permonth basis, 15% less than the non-case managed children, resulting in a savings of $238,000,000 for fiscal year 2010. Milliman Report for the North Carolina Division of Medical Assistance, December 15, 2011 Community Care of North Carolina • Cumulative savings of $974.5 million over 6 years (2003-08) • 40% decrease in hospitalizations for asthma. 93% of asthmatics received appropriate maintenance medications • 16% lower ED visits Kevin Grumbach, MD and Paul Grundy, MD, MPH Outcomes of Implement Patient Centered Medical Home Interventions, November 16, 2011 Patient-Centered Primary Care Collaborative at http://www.pcpcc.net/files/evidence_outcomes_in_pcmh.pdf accessed 3/22/11 In RI, The Time is NOW • Multiple PCMH demonstrations and pilots have proven the effectiveness of the medical home model of primary care in improving clinical outcomes and generating financial benefits to payers • CSI-RI (adults) program shows a slowing of inpatient admissions and cost trends at its PCMH sites, as well as a reduction in inpatient admissions by 8% • CSI-RI (adults) practices met >3/6 quality metrics, high patient experience and a reduction in ER use for ambulatory sensitive conditions Why Pediatric Medical Home Demonstrations? • The time has come to harvest these medical home best practices and apply them to pediatric populations for a variety of reasons including: – An investment in patient- and family-centered care for children today will lead to healthier adults tomorrow – Application of medical home for chronic care conditions builds efficiencies in care between primary and subspecialty care – Parents receiving care in a medical home will begin to expect these services for their children – Employers will begin to use pediatric medical homes as a selection criterion for their benefit plan purchase decisions – Investment in the pediatric medical home enhances the relationship with the member/family and provider network which supports value proposition of insurers Practice Transformation Lessons Learned from CSI-RI (Adults) 1. Engage practices early in initiative design 2. Team based care is central 3. Measurement is hard, and requires strong commitment from practices to work 4. Practices need to incorporate thinking about measurement into their processes of care 5. Financial incentives can drive change in a practice and in patient outcomes Most important CSI-RI lesson Change is possible with – 1. committed leadership 2. the right incentives 3. the proper support 1 + 2 + 3 + you = CSI-Kids Thank you Pediatric Centered Medical Home Tina Spears, RIPIN Our Family Brothers Ahanu, Taquonck, and River The center of our family, our boy Taquonck Race to the Top Early Learning Challenge Michele Palermo, Associate Director Rhode Island Department of Education What Is The Race To The Top Early Learning Challenge? • A $500 million federal competitive grant program to help states build more efficient and effective early learning systems for young children-infants, toddlers & preschoolers-and their families. - RI was one of 9 states to be awarded a grant • Intent was to “Challenge states to build a coordinated system of early learning and development that ensures that many more children from low-income and disadvantaged families, from birth to age 5, have access to dramatically improved early learning and development programs and are able to start kindergarten with a strong foundation for future learning.” 38 RTT-ELC Projects •The RTT-ELC grant work is organized by projects. Each project has a Scope of Work (SOW) document approved by the Feds which includes a budget, staff, activities, milestones and deliverables. •Projects include: ―Program Quality Standards, Alignment, and Measurement ―Early Learning and Development Standards ―Child Assessment ―Early Learning Workforce Development ―Program Quality Improvement ―Early Learning Data System ―Grant Management •Each Project is managed by a inter-agency Core Team which includes state staff assigned to project activities and a liaison from the RI Early Learning Council 39 Child Assessment: Key Activities •Provide professional development opportunities to support reliable child assessment and to support the use of assessment data to inform practice. • Expand the reliable use of Teaching Strategies GOLD in early learning programs. ―Early Intervention ―Community-based early care and education ―Technological supports •Increase developmental screening rates ―Pediatric practices (B-3) ―Child Outreach (3-5) ―Issue intervention grants tied to screening results •Develop or identify valid, reliable, and appropriate K-entry assessment and a plan to pilot the K-entry assessment by the school year 2014-15. 40 Developmental Screening Blythe Berger, Team Lead Rhode Island Department of Health HEALTH-Developmental Screening Support Primary Care Providers to increase screening rates ― ― ― ― ― Support the Implementation of screening in primary care On-going Communication with Provider community Coordinate efforts with other states engaged in similar work Work with state Medicaid office around sustainability plans Support Quality Improvement in practices HEALTH-Developmental Screening • • Share Information Short Term ― ― ― • Support use of electronic screening tools Share screening information electronically with KIDSNET Enhancements to KIDSNET to accept information Longer Term ― ― Share information from screening with electronic health records Link HEALTH data with Department of Education data HEALTH-Developmental Screening Additional Supports • Funds to support practices to implement evidence based interventions ― • Funds for Physician Liaison ― • Co-location of mental health or Parent education Assist HEALTH in working with primary care providers Quality Improvement ― Assist primary care providers to engage in quality improvement activities that will increase screening rates CSI-kids Not just the little adults Patricia Flanagan, MD Hasbro Children’s Hospital Issues Unique to Children and Adolescents • How do we operationalize the Patient Centered Medical Home for child health care systems versus adult health care systems? • The “5 D’s” 5 “D’s” • Development – Health Care for children is a resource that enhances children’s upward developmental trajectory – For children with chronic conditions, the prevalence & severity change with age, so too do the resources needed from the practice. Focus of preventive services are habilitative vs rehabilitative Development • Care coordination needs change as children and teens grow and develop • Developmental services focus on maximizing potential and independence rather than regaining loss • Evaluation of PCMH must include functional and developmental outcomes • The Team is different Development • The special issues of adolescents and their transition to adulthood, including confidentiality and consent, must be addressed Dependency • Community collaboration and coordination must include early ed/child care, schools, and families as key partners • Services, supports and evaluation must include the functioning of families, recognizing that most children have minimal autonomy in health care but that this increases as part of the developmental process Differential Epidemiology • Children are primarily healthy • Epidemiology of chronic conditions differs from adults • Beyond obesity, mental health, and asthma, categorical conditions are rare Differential Epidemiology • Prevention is critical, especially for obesity, asthma and mental health • Programs should address chronic conditions non-categorically rather than disease-specific • Children need access to pediatric sub-specialists who can coordinate with each other as well as the medical home, requiring considerable clinician and practice resources. Demographic Patterns • Children have disproportionately high rates of poverty • The pediatric population is more ethnically and racially diverse than the adult population Demographics are Unique • Understanding and addressing social determinants of health is imperative to building a effective health care system for children • Evidence-based interventions (Head Start, NFP..) and their coordination with medical homes is essential and demands expanding the Team • Addressing disparities (SES and racial/ethnic) must be a priority in child health, with implications for adult health Dollars • Payor Differences • Return on investment Similarities • Care Coordination is an essential resource • Continuity of care over time/transitions • Centered around Patient, family and community • Comprehensive: Preventive/acute/chronic • Culturally Competent and compassionate Promise of CSI-Kids • Practice transformation • Data gathering and analysis at the practice level • Payment reform that supports the need for nontraditional reimbursed services, rewards wellness and optimal developmental progress • Longer term ROI, more complex tracking of ROIcross sector (health, education, child protection, JJ, economic..) Next Steps • Organizational structure to mesh with current successful CSI structure • Partner with community/payors/state resources to start with improving rates of developmental screening • Improve the relationship between CEDARRS and PCMH by building intentional collaborations, metrics of care coordination Actions • 1. Join us at the stakeholders (providers, payor, partners) meeting – – – – Date: Friday, March 1, 2013 Time: 7:30 – 9:00 AM Location: RI Department of Administration, Conference room B Address: 1 Capitol Hill, Providence, RI 02908 • Join committees to develop contracts, define metrics, develop practice transformation strategies CSI Steering Committee Executive Committee Patient Advisory Group Marketing/ Communication Working Committees Data and Evaluation PTST Practice Reporting Payment Reform/ Contract Service Expansion and Integration 60 Questions • Patricia Flanagan, MD, CoChair, Hasbro Children’s Hospital • Elizabeth Lange, MD, CoChair, Waterman Pediatrics SINCERE THANK YOU!!! To CSI-RI, EOHHS,OHIC, HEALTH To RI Foundation To RI AAP And Mostly, to all of you who came to hear about CSI-Kids!!